Physiotherapy Theory and Practice, 24(6):423–429, 2008

Copyright r Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online

DOI: 10.1080/09593980802511821

After-hour physiotherapy services in a tertiary

general hospital

Edwin C W Lim, BHSc (Physiotherapy), Jinyu Liu, BHSc(Physiotherapy), Meredith T L Yeung, BHSc (Physio.), MPhysio

(Cardiothoracic Physio.), and Wai Pong Wong, BPhty (Hons), PhDDepartment of Physiotherapy, Singapore General Hospital, Singapore

The aims of the present study were to describe the after-hour physiotherapy services in a tertiarygeneral hospital, the patients and their demographics, and to determine which independent variableswould predict physiotherapists’ referrals to after-hour physiotherapy. A retrospective record reviewfrom April 1, 2004, to April 30, 2005, identified 992 patients (mean age 63.8 years; 95% confidenceinterval [CI] 62.6–65.0 years) who were either referred by daytime physiotherapists (68%) or referredby medical practitioners for urgent attendance after hours (32%). Pneumonia was formally diagnosedmedically in 20% (n¼ 197) of the patients. Of all the patients who had surgery, upper abdominalor thoracic incisions formed the majority (61%; n¼ 236). Whether patients had upper abdominal/thoracic surgery (estimated odds ratio 3.4; 95% CI 2.3–4.9) and the presence of pneumonia (2.8; 95%CI 1.9–4.2) were two independent factors identified from a logistic regression model predicting daytimephysiotherapists’ referral of patients to after-hour service. This model correctly predicted 65.5% of thecases. Most patients were seen for mucociliary clearance. Referral behaviour by physiotherapistsreflects the basis of their clinical decision making and has implications for practice, training, andfurther research.

Introduction

Access to physiotherapy in a hospital, unlikemedical and nursing services, is not alwaysavailable throughout the whole day or on alldays in a week. Twenty-four-hour availability ofphysiotherapy is however advocated in someareas of the hospital, such as the intensive careunits (ICUs) (Oh, 2003).

Provision of physiotherapy to ICU at nightvaries widely in different countries. Accordingto one survey, in the United Kingdom, 23 of 29(79%) ICU physiotherapists reported such pro-vision, compared to none in Germany, Portugal,

and Sweden (Norrenberg and Vincent, 2000). Inearlier surveys, 24-hour on-call physiotherapyservice was reported by 31 of 32 (97%) ICUs inthe United Kingdom but only 18 of 37 (49%)in Australia and none in Hong Kong (Jones,Hutchinson, and Oh, 1992). An Australiansurvey reported 19 of 42 (45%) hospitals with24-hour on-call or nightshift physiotherapy ser-vice (Ntoumenopoulos and Greenwood, 1991).More recently, less than 3 of 77 Australian ICUsinterviewed reported 24-hour access to physio-therapy (Chaboyer, Gass, and Foster, 2004).A trend of diminishing 24-hour access wasalso noted by one Canadian hospital, which

Accepted for publication 28 December 2007.

Address correspondence to Edwin C W Lim, Department of Physiotherapy, Singapore General Hospital, Outram Road,

Singapore 169608. E-mail: edwin.lim.c.w@sgh.com.sg

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reported a reduction of its after-hour physio-therapy services from 24-hour to only eveningavailability, apparently without compromiseto clinical care (Prendergast and O’Callaghan,1996). Thus, 24-hour access to physiotherapy isuncommon in most countries except the UnitedKingdom.

Weekend daytime access to physiotherapy ismore common; for instance, such weekend ser-vices have been reported to be available in 85 of102 (83%) ICUs in western Europe (Norrenbergand Vincent, 2000), 51 of 77 (66%) in Australia(Chaboyer, Gass, and Foster, 2004), and 33 of 37(89%) in New Zealand (Reeve, 2003). In sum-mary, weekend daytime access to physiotherapyservices is available to a majority of hospitals inmany parts of Europe and Australasia.

After-hour physiotherapy services, defined asweekend daytime access and evening hours, areless commonly available than weekend daytimeaccess alone, and the profile of the ‘‘after-hour’’patients, for whom these services have beencreated, has not been described. Furthermore,how these patients’ characteristics, such as age,pulmonary diagnoses, and concomitant medicaland surgical conditions, influence the practiceof referral for after-hour visits deserves to beinvestigated. Implicitly, profiling the ‘‘after-hour’’ patients may also reveal the clinicaldecision-making basis used by referrers of after-hour physiotherapy services. Most researchwork in the area of after-hour physiotherapy hasfocused on competency training, quality assur-ance, and maintenance of clinical standards toprepare after-hour or on-call physiotherapistsfor the services (Byrne, 2002; Cross, Harden,Thomas, and ten Hove, 2003; Dixon and Reeve,2002; Thomas, Cross, Harden, and ten Hove,2003). It is however similarly important to knowthe type of patients and their clinical conditionsbefore designing appropriate competency train-ing programmes for these physiotherapists.Reasons for referring for after-hour physio-therapy (i.e., improving lung volume or assistingin mucociliary clearance) also impact the skillexpectation.

Therefore, the present study aims to describethe after-hour physiotherapy services in onetertiary general hospital, the patients and theirdemographics, and to determine which inde-pendent variables predict if physiotherapists willrefer to after-hour physiotherapy.

Methodology

A retrospective review of after-hours servicerecords at the Singapore General Hospital Depart-ment of Physiotherapy was undertaken by theprimary investigator. Singapore General Hospitalis a tertiary hospital with about 1,400 beds. Normalworking hours are 8 AM to 5 PM weekdays and 8 AM

to 12 noon on Saturdays. Outside these hours,after-hour physiotherapy services are available andstaffed by one physiotherapist on shift as follows:

K 5 PM to 9 PM every eveningK 9 PM every night to 8 AM the next morningK 12 noon to 5 PM on SaturdaysK 8 AM to 5 PM on Sundays.

The period for review was from April 1, 2004,to April 30, 2005. Although after-hour phy-siotherapy services have been available sinceJuly 1995, records earlier than April 1, 2004,were less complete. A new after-hour referralform was introduced on this date, allowing moreaccurate information being retrieved and recor-ded. The retrospective study was approved bythe institutional ethics committee.

Information on patients’ age, gender, clinicaldisciplines, primary and secondary diagnoses(up to three), and surgical sites, if surgery wasundertaken, was recorded. Whether the case was areferral by physiotherapists (‘‘physiotherapist-referred cases’’) or by medical staff (‘‘medical-staff-referred cases’’) was also identified andcoded. This after-hour system is therefore notjust an ‘‘on-call’’ system, because the phy-siotherapist is attending to cases scheduled byhis daytime colleagues, as well as allowing timeto assess and accept medical-staff-referred foremergency cases. Reasons for referrals wereretrieved for analysis. On the referral forms werereasons for referrals, namely, ‘‘increase ventila-tion,’’ ‘‘facilitate mucociliary clearance,’’ and‘‘optimize ventilation-perfusion matching’’ forreferring physiotherapists to indicate. Somephysiotherapists checked more than one reasonfor referrals on the referral forms.

Statistical analysis

Descriptive statistics were calculated for age.Frequencies were determined for all other nominaldata. Chi-square statistic was used to determine

424 Lim et al. /Physiotherapy Theory and Practice 24 (2008) 423–429

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significant differences between number of phy-siotherapist- and medical-staff-referred cases,number of male vs. female patients, and numberof referrals frommedical vs. surgical disciplines. Inaddition, differences between physiotherapist- andmedical-staff-referred cases in terms of gender,clinical disciplines, and discharge status, as wellas differences between medical and surgical dis-ciplines in terms of each diagnosis were deter-mined by 2� 2 contingency tables. Significantdifference was established as p<0.05. Logisticregression analysis (using SPSS 14.0 for Windows,SPSS Inc, Chicago, IL 60606) was conducted todetermine which independent variables wouldpredict physiotherapists’ referral of patients forafter-hours physiotherapy.

Results

Nine hundred ninety-two patients (mean age63.8 years; SD 17.7; 95% confidence interval [CI]62.6–65.0 years) were identified from the after-hour records from April 1, 2004, to April 30, 2005.Because the total number of attendances duringthis period was 6,752, these patients were attendedan average of 6.8 times after hours. Table 1describes the characteristics of the patients atten-ded after hours during the review period.

Physiotherapist-referred cases (68%) were sig-nificantly more than medical-staff-referred cases(32%; w2¼ 68.33; df¼ 1; p¼ 0.001). There was nosignificant difference in terms of gender, clinicaldisciplines, and patient outcome between phy-siotherapist-referred and medical-staff-referred

cases. When combining all the cases (physiothera-pist-referred and medical-staff-referred cases),over 60% were men (n¼ 607; w2¼ 25.16; df¼ 1;p<0.001), significantly more than women. It wasnot practicable to identify whether the patient wasin surgical intensive care unit, intermediate carearea, high dependency unit or general ward, as thesame patient could be moved from one level tothe other on different days when after-hour phy-siotherapy was provided. Therefore, patients’clinical disciplines were identified as either surgi-cal or medical. Patients from surgical units (65%;w2¼ 79.74; df¼ 1; p<0.001) were significantlymore than those from medical units. The onlypatient outcome information that could begleaned from the records was discharge status,which was either death or discharged from thehospital (which could mean either to home orstep-down institution; however, the exact figureswere unavailable). One-year mortality rate of thepatients seen after hours was 28.8%.

The medical staff referred a total of 197 casesto after-hour physiotherapy with pneumonia asthe primary diagnosis. This accounted for 20%of the total patients referred (N¼ 992). In addi-tion, 30 patients were referred with an atelectasisdiagnosis (3.0%); 13 patients with bronchiectasis(1.3%); and 19 with chronic obstructive pulmo-nary disease (1.9%). Patients from the medicalunits were more likely to carry the diagnosesof pneumonia and bronchiectasis than patientsfrom the surgical units (pneumonia: odds ratio[OR]¼ 4.52; 95% CI 3.17–6.43; w2¼ 75.04;p<0.0001; bronchiectasis: OR¼ 7.97; 95% CI2.18–29.22; w2¼ 11.496; p¼ 0.001). The next

Table 1. Characteristics of the patients seen for after-hour physiotherapy.

Physiotherapist-referred cases Medical–staff-referred cases

Number of cases (%) 675 (68.0) 317 (32.0)*Age (years), mean (95% CI) 64.0 (62.6, 65.4) 63.3 (61.1, 65.5)Male, number (%) 408 (41.1) 199 (20.1)Female, number (%) 241 (24.3) 144 (14.5)Surgical disciplines, number (%) 343 (34.6) 299 (30.2)Medical disciplines, number (%) 173 (17.4) 177 (17.8)Death, number (%) 207 (20.9) 79 (7.9)Discharged from hospital, number (%) 443 (44.7) 263 (26.5)

*Significant between physiotherapist- and medical-staff-referred cases at p<0.05.

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three most frequent primary diagnoses that werereferred were: 1) cancer (12%); 2) sepsis (6%);and 3) fracture (6%).

About 60% of the patients from the surgicalunits had surgery (n¼ 386). Of all the patientswho had surgery, upper abdominal or thoracicincisions (n¼ 236) formed the majority (Figure 1).

Selected factors such as patients’ age, gender,clinical disciplines, pulmonary diagnoses, surgi-cal sites, and eventual discharge status wereentered into a binary logistic regression modelusing the backward stepwise likelihood method(Table 2). Given the limited information basedon this retrospective audit, the model was stillable to predict about two-thirds (65.5%) of theresponses correctly. The model, based on theavailable number of variables in this retro-spective study, identified the presence of pneu-

monia and upper abdominal/thoracic surgery asthe only two significant independent factorspredicting physiotherapists to refer patients forafter hours (Hosmer and Lemeshow goodness offit w2¼ 0.591; df¼ 4; p¼ 0.964).

Figure 2 shows the reasons for referring toafter-hour physiotherapy indicated in the phy-siotherapist-referred cases. A patient could bereferred to after-hour physiotherapy for morethan one reason. Thus, we totaled up the fre-quency of each reason indicated by the referringphysiotherapists, rather than the frequency ofreferrals carrying a particular reason for referral.Therefore, percentages in Figure 2 added up to100%. We did not analyze the reasons forreferring in the medical-staff-referred cases,because not all after-hour physiotherapists indi-cated the reasons after attending to the patient.

Table 2. Predictors of physiotherapists’ referral to after-hours service.

95% CI for Exp(B)

Factors B S.E. Wald df Sig. Exp(B) Lower Upper

Upper abdominalthoracic surgery

1.220 0.190 41.381 1 0.000 3.389 2.336 4.915

Pneumonia 1.028 0.208 24.457 1 0.000 2.796 1.860 4.202Gender �0.269 0.156 2.959 1 0.085 0.764 0.562 1.038Atelectasis 0.773 0.450 2.949 1 0.086 2.166 0.896 5.233Bronchiectasis 0.754 0.682 1.221 1 0.269 2.125 0.558 8.092Age �0.001 0.004 0.024 1 0.874 0.999 0.991 1.008Constant 0.495 0.234 4.490 1 0.034 1.641

B: regression coefficient; S.E.: standard error of B; Wald: statistic; df: degree of freedom; Sig: significance; exp(B): estimated

odds ratio; 95% CI: 95% confidence interval for estimated odds ratio.

9%

61%

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0%

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30%

40%

50%

60%

70%

head andneck

upperabdominalor thoracic

lowerabdominal

limbs orspine

skull orbrain

Figure 1. Surgical sites in patients who had surgery.

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Discussion

This retrospective study presented informationabout patients seen after hours in a tertiary gen-eral hospital. Patients were on average 63–65 yearsold, majority were male, most were admittedunder surgical units, and usually were referred bydaytime physiotherapists.

Older patients (>65 years) account for overhalf of ICU admissions (Marik, 2006). They alsohad higher mortality rate, even after survivingICU admission. For example, older patients(>65 years) after discharge from ICU hadhigher 1-year mortality rate (49% vs. 31%) thanyounger patient (Rockwood et al, 1993). The1-year mortality rate of 29% in the currentretrospective study cannot be attributed to morefrequent access to physiotherapy in patients whowere at risk of developing or had developedrespiratory compromise. Further studies inves-tigating long-term outcomes of at-risk patientswho received 24-hour access to physiotherapymay be warranted.

In the current study, over 60% were malepatients, with the gender proportions unaffectedby whether they were physiotherapist-referredor medical-staff-referred cases. Gender, accord-ing to our logistic regression, was not a predictorof physiotherapists’ referral pattern, suggestingthat there could be gender-specific effects onincidence of respiratory deterioration requiringemergency physiotherapy intervention. Studiesexamining gender differences in the course andoutcome of trauma and critical illness have in fact

shown that men tended to develop infectiouscomplications (Croce et al, 2002) and had poorerprognosis after infection (Imahara, Jelacic, Junker,and O’Keeefe, 2005) than women.

Surprisingly, patients with pulmonary diag-noses did not form the majority in this sample,suggesting perhaps that physiotherapists tendedto adopt a preventative approach for patientswho might carry the risks of developing post-operative pulmonary complications or nosoco-mial pulmonary infections.

In this study, presence of upper abdominal/thoracic surgery in a patient, compared to no sur-gery or no upper abdominal/thoracic surgery,increased the likelihood of physiotherapists referr-ing the patient for more frequent (i.e., after-hour)physiotherapy sessions by 3.4 times (95% CIranged from 2.3 to 4.9; Table 2). Evidence sup-porting the preventative roles of after-hour physio-therapy involves mostly surgical patients (Ball,1999; Berney, Stockton, Berlowitz, and Denehy,2002; Ntoumenopoulos and Greenwood, 1996;Wong, 2000). This body of evidence is primarily atlevel III or IV, which according to Sackett et al.(2000), refers to case-control studies and case series,respectively. In at-risk elderly patients 18–24 hoursafter abdominal surgery, significantly lower intra-pulmonary shunt fraction (mean Qs/Qt¼ 17%,normally below 5%) were found in those whoreceived ‘‘daytime plus evening’’ (n¼ 16) physio-therapy compared to those (mean Qs/Qt¼ 22%)who received ‘‘daytime only’’ (n¼ 15) physiother-apy (Ntoumenopoulos and Greenwood, 1996).Thus, the addition of one more physiotherapysession in the 24-hour day appeared to be asso-ciated with less deterioration of gas exchange.Physiotherapy consisted of combinations of posi-tioning, gravity-assisted drainage, breathing exer-cises, manual techniques, coughing, and airwaysuctioning. In this same study, where at-riskpatients were alternately allocated to ‘‘daytime plusevening’’ and ‘‘daytime’’ groups, the incidence ofpostoperative atelectasis, however, was not signifi-cantly different between groups (Ntoumenopoulosand Greenwood, 1996). But in a study using his-torical control, introduction of weekend referralcriteria for patients after surgery was associatedwith an almost fourfold decline (63% to 16%) inthe number of patients in whom deterioration inpulmonary status occurred over the weekend,resulting in 13% reduction in the incidence of pos-toperative pulmonary complications (Ball, 1999).

21%

52%

27%

0%

10%

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30%

40%

50%

60%

increase lungvolume

facilitatemucociliaryclearance

reduce work ofbreathing

Figure 2. Reasons for providing after-hour respiratory physio-

therapy.

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In a case-control retrospective review of patientswith acute quadriplegia, patients (n¼ 7) who wereextubated earlier but received after-hour physio-therapy had significantly shorter length of stayin ICU than patients (n¼ 7) who just had tra-cheostomy in situ (Berney, Stockton, Berlowitz,and Denehy, 2002). The cost of intubation,mechanical ventilation, and ICU admission is alsoconsiderable. In one case report, a patient witha known history of chronic lung disease whounderwent exploratory laparatomy and subse-quently developed acute respiratory failure wasestimated to incur 1.5 times the cost had he beenintubated and mechanically ventilated over atwo-day stay in ICU, instead of receiving morefrequent daytime and after-hour physiotherapyduring the same period (Wong, 2000).

After-hour patients from the medical discip-lines were likely to carry a diagnosis of pneu-monia (more than four times compared topatients from surgical disciplines) and bronch-iectasis (almost eight times). Although the evi-dence for respiratory physiotherapy, let alonemore frequent physiotherapy, for bronchiectasisis modest (Rosen, 2006), physiotherapists in thissample were referring patients with bronch-iectasis for more frequent therapy sessions.Because the main problem in bronchiectasis issecretion retention (Cecins, Jenkins, Pengelley,and Ryan, 1999) and the main reason for after-hour referral in this sample is mucociliaryclearance, it is probable that physiotherapistsbelieved that more frequent physiotherapy couldimprove outcome. To date, no evidence existswhich supports this belief. Similarly, presence ofpneumonia in a patient increased the likelihoodof physiotherapists in this sample to refer thepatient for after-hour physiotherapy by 2.8 times(95% CI 1.9–4.2; Table 2), but the evidencesupporting this practice is still lacking. Furtherresearch in this area is therefore needed.

We were more interested in predictors fordaytime physiotherapists’ referral pattern thanafter-hours medical referral because the formeraccounted for 68% of the referrals. Logisticregression in the current study, based on limitedvariables, identified only two independent pre-dictors of physiotherapists’ after-hour referralbehaviour. Although the regression model cor-rectly predicted two-thirds of the cases despitelimited variables, further studies could examineother potentially contributing variables such as

physiotherapists’ age, years of experience, quali-fication, and seniority.

That less than a third of the cases have beenreferred by medical staff implies opportuni-ties for physiotherapists to further market thebreadth and depth of their services. A limitationin the current retrospective audit is the lack ofinformation on the ranks and seniority of thereferring medical staff, as different target groupsmay respond differently to such marketingefforts. From our observations, most of thecases referred by the medical staff were formucociliary clearance, which is not the only rolefor after-hours physiotherapists. This areadeserves further investigations.

Despite the limited evidence, ‘‘24hr/day avail-ability of measures aimed at pulmonary secretioncontrol, specifically chest physiotherapy and pos-tural drainage, as clinically indicated (pp 276)’’ isrecommended for patients with acute respiratoryfailure on mechanical ventilation (Society ofCritical Care Medicine, 1991). Recent guidelineson ICU staffing also highlighted the need for 24-hour access to appropriate respiratory care prac-titioners, however, more explicitly referring torespiratory therapists (Haupt et al, 2003). Thisconcept of a full-time dedicated 24-hour respira-tory therapist for ICU is well established in NorthAmerica, but not in Europe and Australasia,where physiotherapy availability after hours isconsidered essential (Oh, 2003). Whether 24-houravailability of respiratory therapy is economicallycomparable with physiotherapy in the currentatmosphere of rationed resources is unknown.

The current description of our after-hoursphysiotherapy service may interest individualsconcerned with training and auditing after-houror on-call physiotherapists (Byrne, 2002; Cross,Harden, Thomas, and ten Hove, 2003; Dixonand Reeve, 2002; Thomas, Cross, Harden, andten Hove, 2003). Over half of the reasons forreferral was for mucociliary clearance. Almosttwo-thirds were patients from the surgicaldisciplines, of whom over 60% had surgicalincisions. The challenge for the after-hour phy-siotherapist will be to assist patients with surgi-cal incisions to achieve effective mucociliaryclearance, besides improving lung volume.About 27% of the reasons for referral were forreducing the work of breathing, particularly inpatients who were acutely breathless. This isyet another challenge for the physiotherapist

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working in the acute care setting to provideeffective intervention for such patients duringafter hours. Thus, information from the currentprofiling of after-hour patients provides somefocus for future education and training efforts.

Conclusion

This retrospective review is the first study toprofile the typical patients seen after hours. They areusually patients with pneumonia or ‘‘at-risk’’ surgi-cal patients with upper abdominal/thoracic incision.Most patients were seen for mucociliary clearance.Profiling the ‘‘after-hour’’ patients reveals the clin-ical decision-making basis used by physiotherapistreferrers of after-hour physiotherapy services.

Acknowledgments

The authors thank all physiotherapists (whowere either on evening or night duty) and doctorsfor their cooperation in making this retrospectivereview possible.

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